1. • The lips are an important part of an individual’s persona contributing to aesthetics as well as having an important
functional role. Lips are involved in several complex functions, including emotional expression, oral sphincter
function, and speech articulation. The primary aim of lip and oral commissure reconstruction is the preservation of
function. Oral competence, muscle function, lip sensation, and adequate mouth opening are the four main goals
for achieving normal oral function. The cosmetic aims of lip reconstruction include restoring labial symmetry at rest
and when animated. However, oral competence and lip function, rather than cosmetic factors, are the key
determinants of successful lip reconstruction [5-8].
• An appropriate lip reconstruction method should be chosen according to the defect size. Reconstruction of large
upper lip defects is a major challenge for plastic surgeons.
• The Abbé-Estlander flap surgery is a cross-lip procedure that is valuable in repairing a defect on the lower lip using
a full-thickness flap, consisting of the skin, muscle and mucosa, from the upper lip.
• The authors present a case of successful lower lip reconstruction with a staged, Abbé-Estlander lip switching flap
with commissuroplasty as an illustrative example.

2. • CASE REPORT
• A XXX-old man visited our department for basal cell carcinoma affecting the lower lip. On physical examination,
the mass was an irregularly shaped ulcerative lesion measuring xxx cm No distant metastases were identified ???
• A xxx -year-old male has presented with an ulcerating lip nodule in the external one third of the lower lip,
measuring about xxx cm across its long and short axes.
• Under local anesthesia, the mass was excised under MOHS surgery protocol. After excision of the tumor, an
extended Abe- Estlander flap was applied,.MOHS excision of the tumor was followed by delineation of the
triangular Abbé-Estlander flap from the upper lip, in which the medial hinge point of the base was chosen as the
pedicle. Then, the flap elevation was carried out from the lateral commissure and then was transferred into the
lower lip defect.
• in the futute a Kazanjian-Roopenian type I commissuroplasty can be performed to correct the lip asymmetry by
lengthening the right oral commissure (Fig. 3A).
• Postoperative complications, such as venous return disturbance, infection, and seroma were not observed. Oral
ingestion was possible immediately after surgery. Although minimal bilateral asymmetry persisted, the mouth could
be opened sufficiently, and the oral commissure was symmetrical after commissuroplasty.
• at x month follow-up, we observed improvement in the functional and aesthetic aspects of the lips
• The patient is currently performing his daily activities with no apparent compromise in orbicularis oris strength or
oral continence.

7. INTRODUCTION
Reconstruction of the lip becomes an especially challenging task due to various anatomic factors. The lack of any
substantial fibrous framework increases the risk of anatomic distortion through wound contraction and may lead
to poor functional and aesthetic outcomes. The quality (i.e., color, texture, elasticity) of the skin and
mucosa of the lips are difficult to match with distant flaps. Hence, local tissues provide the best results. There are
various techniques for the lip reconstruction like Gillies fan flap, Karapandzic flap,
Bilateral advancement flap, Bernard-Burow flap, Nasolabial flap, Perialar crescentic advancement flap,
Dieffenback method Depressor angulioris flap and free flap. Another technique that has been proven
very useful for the reconstruction of lip defects is the use of Abbe Estlander flap.
Given the size of the primary defect and the flap-to-defect ratio of size, the degree of microstomia was acceptable.
Even with other myriad of reconstructive options at surgeons' disposal, the Abbé-Estlander lip-switching flap is a
reliable, and less morbid method of lower lip reconstruction for surgical candidates. The authors illustrate an
exemplary case in which a relatively large lower lip defect was successfully repaired using an upper lip flap of a
significantly smaller size in an Asian subject of advanced age, without any remarkable long term sequelae which
have traditionally been associated with the trans-oral lip switching flap technique.

9. • The lips are perhaps the single important anatomical structures which dynamically determine the overall
impression of the overtone of the facial expression. Subtle disturbance in the dynamics of the lip elevators and
depressors may translate into an exaggerated distortion of the mid- and lower face region. Therefore, this dynamic
equilibrium between the opposing lip muscles must be properly restored with an effective reconstruction technique
after creation of defects, which may result from congenital anomalies, trauma1, wide local excision for malignant
neoplasm2, and a variety of other inciting events. Delicacy of the issues concerning the anatomic and histological
characteristics of the region mandates a premediated, meticulous repair strategies coupled with an impeccable
execution of whatever the reconstructive option the surgeon chooses to employ. Although lower face tends to be
more or less a forgiving region for surgeons, the lack of any significant supporting fibrous framework3
nevertheless makes the region vulnerable to distortion of the free margins. Furthermore, the uniqueness of the
vermillion border makes it virtually impossible to find the suitable distant tissues that would blend well into the
surrounding tissue when the flap is juxtaposed by the neighboring tissues4.
• This, for all practical purposes, leaves surgeons with the utilization of local flaps. Although a long list of
reconstructive options have been in use since as far back as three millenia5, (e.g., Gillies fan flap6, Karapandzic
flap7, Bilateral advancement flap, Bernard-Burow flap8, Nasolabial flap, Perialarcrescentic advancement flap9,
etc.), the transoral, lip-switching Abbé-Estlander flap has been known as a reliable technique which delivers
consistent results and satisfaction for surgeons and patients alike. The flap belongs to the category of full-thickess
myocutaneous flap, which feeds off a pedicle from the labial artery. The authors describe a case of lower lip defect
successfully repaired with a two-stage, Abbé-Estlander flap in an Asian male with a significantly smaller flap from
the upper lip.

10. Fig. 2. (A) At completion of the first stage operation and (B) 8 weeks postoperative.
Ann Dermatol. 2017 Apr;29(2):210-214.
https://doi.org/10.5021/ad.2017.29.2.210

11. Fig. 1. (A) Clinical photograph of the lesion with extensive involvement of the mid-to-left portion of the lower lip. (B) Wide wedge
excision of the primary tumor is followed by design of the flap.
Ann Dermatol. 2017 Apr;29(2):210-214.
https://doi.org/10.5021/ad.2017.29.2.210

12. Fig. 3. Histopathological findings of the excised tumor at (A) low magnification (H&E, ×40) shows poorly-differentiated
squamous cell carcinoma showing diffuse invasion. Superficial portion of the underlying skeletal muscle is also involved (inset:
×200). Nuclear pleomorphism and intratumoral nercrosis are evident in (B); H&E, ×200.
Ann Dermatol. 2017 Apr;29(2):210-214.
https://doi.org/10.5021/ad.2017.29.2.210

13. • A 71-year-old Korean male, a farmer by profession, has presented with an elliptical, friable,
ulcerating lip nodule in the middle one third of the lower lip, measuring 1.5×2 cm across its long
and short axes, respectively. The tumor caused a significant edema and distortion of the vermilion
border (Fig. 1A). A 4-mm punch biopsy was taken and the pathology report showed a poorly-
differentiated squamous cell carcinoma with deep invasion down to the muscle. Preoperative
workup included head and neck computed tomography, which revealed no infiltration of the tumor
into the adjacent tissue and no significant enlargement of local lymph nodes. Because the
projected extent of tumor extirpation, amount of blood loss, and the risk of wound infection, the
patient was admitted the day before operation and prophylactic intravenous antibiotics was
administered. On the operating table, a wedge-excision of the tumor with a generous tumor-free
margin created a triangular defect measuring about 5.1 cm at its base and 4.8 cm and 4 cm at its
vertical limbs (Fig. 1B). Delineation of a right-triangular Abbé-Estlander flap from the upper lip,
measuring about 1.5×1.5×2.3 cm was done and the flap was to be pedicled medially. Flap
elevation was then carried out from the lateral commissure, and then the pedicled flap was pivoted
180 degrees and interposed into the lower lip defect. The flap was sutured into place with
approximation of the two edges of orbicularis oris muscle using a 5-0 absorbable, followed by the
closure of the mucosal side with a 5-0 vicryl. Skin suture was done with a 6-0 nonabsorbable; the
donor site was closed primarily with the same suture material (Fig. 2A). The pathology report
provided the final diagnosis of poorly differentiated squamous cell carcinoma of the lip, with the
carcinomatous cells penetrating down to muscle (Level V invasion). Involvement of
peripheral/deep margins, lympho-vasculature, and perineurium was not seen (Fig. 3). For the
following three days after the first stage, the patient was allowed liquid diet only, and after
tolerability was affirmed, it was gradually replaced with increasingly more solid types of diet. Three
weeks later, division of the pedicle “hinge” point was performed and the flap was allowed to be set
in place. He has hence been followed up with outpatient visit to the clinic every four weeks. The
patient reported that he hardly experienced weakening of orbicularis oris muscle strength or oral
incontinence of solid or liquid content. The degree of microstomia, which is considered more or
less inevitable with the lip switching flap procedures, was considered acceptable, given especially
the size of the primary defect (Fig. 2B).

14. • Lip defects can either be classified as partial defects that involve only skin or mucosa or full-thickness defects
involving skin and muscle, with or without mucosal involvement10. The defect can also be categorized in
accordance to its location, i.e., left, the middle or the right third of, or overlap lesions involving a combination of two
or more of these sites11. The defect may be limited to the cutaneous lip or vermilion or involve the both. More
often than not, the goal is to utilize a smaller sized flap of the upper lip to make up for a larger defect on the lower
lip, where lip malignancies, mostly squamous cell carcinoma, occurs with a greater frequency12. Inevitably,
varying degrees of postoperative microstomia is almost bound to occur. Of note is the proportion of the flap size to
that of the defect in the present case; the triangular defect, measuring about 5.1 centimeters in its base and 4.8
cm and 4 cm at each vertical limb, was successfully repaired with a right triangular-shaped flap of only
1.5×1.5×2.3 cm in dimension. This minimization of the secondary defect allowed us to salvage the commissure
and hence the more acceptable cosmetic outcome. Although there is no single consensus as to the “optimal” ratio
of the flap to the defect size (i.e., yielding the best aesthetic results without flap failure) our case demonstrates that
it may be as small as one to three, granted that the patient represents lower surgical risk group, and flap insetting
is technically sound. When properly executed and appropriate postoperative care is given, the Abbé-Estlander flap
surgery is associated with minimal risk of flap failure13. Our patient was free from any significant postoperative
morbidity such as wound dehiscence or necrosis.
• In any case of lip and perioral reconstruction, preservation of the muscle function should be prioritized. Successful
restoration of adequate lip function and strength hinges on the structural integrity of orbicularis oris muscle with its
reinnervation14, 15, 16. We postoperatively evaluated the integrity of orbicularis oris muscle with mouth opening
and closing, oral continence and presence or absence of lip asymmetry and dynamic distortion, at four-week
intervals postoperatively. Our patient has not experienced any difficulty in phonation or lip incompetence up to
three-month postoperative follow-up. The integrity of the muscle function after the surgery has been well
documented in a previous study by Zhai et al.17. As demonstrated by our case, restoration of adequate lip function
and its natural positioning traditionally embodies a two-stage procedure with the commissuroplasty step performed
three weeks after the flap insetting, although a handful of authors have reported success with single-stage
techniques18, 19.
• In reconstruction of lower lip with defects of significant size in Asian subjects, selection of the right repair technique
would be dictated by safety considerations, track record for its reliability, and perhaps most importantly, utilization
of like tissue from neighboring tissues. With a fairly predictable blood supply from branches of the superior labial
artery, rapid neovascularization ensures survival of the pedicle after the second stage “division” in only after 2
weeks after the first stage. Another major strong point from aesthetic perspective is that the final donor scar area
hardly stands out because it was effectively hidden into the nasolabial fold (in case of a more medial defect it